Canada must expand public health care or fall further behind

The Commonwealth Fund’s recent report, Mirror, Mirror, ranked Canada’s health care system as ninth among 11 countries. That elicited everything from scathing indictments of Medicare to a quick dismissal of the report itself. The truth, however, lies very much in between.

Mirror, Mirror should act as a wake-up call to policy-makers and health care advocates across the country that without action we will continue to fall behind.

While critics of our public health care system are quick to call its advocates defenders of the status quo, you will be hard pressed to find anyone taking such a position. No doctor wants to see their patients wait for necessary care. No patient wants to wait longer to see a specialist. Public health care advocates across the country are calling for innovative reforms to our health system, investments in our infrastructure, and expansion of coverage into areas like prescription drugs and dental care.

Before throwing out the proverbial baby with the bathwater, it’s important to look at the categories we do poorly in: equity and access.

It’s an important reminder that Canada’s problem is not too much public funding. It’s not single-payer payment either. In fact, single-payer health systems are administrativelyefficient and equitable.

It’s that our definition of universality where single-payer applies (hospitals and doctors) is too narrow. We need to update what’s covered in our public system to meet the health needs of Canadians in the 21st Century.

With one in five Canadian families reporting they are unable to fill prescriptions due to cost, it’s no wonder Canada ranks low on equity. The affordability of prescription medications has serious health implications as well. Between 5.5 and 6.5 percent of hospitalizations in Canada are attributed to Canadians inability to take drugs as prescribed.

The situation is eerily similar in dental care. A report from the Canadian Academy of Health Sciences in 2014 found that roughly half of Canadians who lacked access to dental coverage through private insurance avoided going to the dentist at all because of the cost. The Ottawa Board of Health has reported a 52 percent increase in emergency room visits for dental services between 2004 and 2014. In fact, in 2014 there were 1,740 avoidable ER visits for dental services in Ottawa alone.

Wait times and access are also a challenge in any health care system. Though the mechanisms we choose to finance health services are vital, we ignore health care delivery at our peril. While Canadians receive high quality, patient-centered care, many wait too long to access it. The good news is that there are great examples from not just around the world, but also within our own borders of how we can (and are) improving accessibility, equity and quality of care.

As is often pointed out, we need to do better at spreading and scaling these innovations. Though there is no cookie-cutter approach to this, there are jurisdictions that do this well from whom we can learn. Health care leaders across the country are taking on this challenge.

There is a lot to be proud of in our health care system. But this pride doesn’t preclude a burning desire for improvement and doing better on health care outcomes.

When premiers met at this year’s Council of the Federation, they agreed to push the federal government to open up a dialogue about pharmacare. And when doctors from across the country meet later this month for the Canadian Medical Association General Council, we will discuss innovation and how to continue to work together to improve our health care system.

It is by expanding and enhancing Medicare, not dismantling it, that we will see Canada rise in the ranks among its international partners.

Danyaal Raza is Chair of Canadian Doctors for Medicare, a family physician at St. Michael’s Hospital in Toronto, and Assistant Professor at the University of Toronto.

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16 comments

sAugust 16th, 2017 at 11:35 am

Agree re need to expand the definition of universality – but WHO decides this is as important to consider as WHAT is covered. Government (provincial and/or federal?) and doctors? What would be the process for decision-making around expansion of coverage? Everyone has inherent biases in what should be covered. Is it possible to have unbiased leadership to move this forward? I think you’d be hard-pressed to find anyone disagreeing with your statement to expand and enhance Medicare, but perhaps some ideas on an approach to how to do so effectively to further this discussion would help. Also- there’s a lot of rhetoric around team-based care, but the hierarchies and systematic ways in which “non-MD” regulated health care professionals are undermined is a problem. One can look no further than Health Debate to see how many articles are MD-written or with a strong MD voice versus non-MD providers.

Accountability to the Federal government to assure transfer payments to the provinces for medical care, to ensure that the allotted money actually gets used for medical care.
A nation wide standard for Family Physician care ensuring that these doctors are paid sufficiently for the care they give.
A removal of a Family Doctor’s Quebec remuneration being penalized if they do not spend the first 3 years of their practice in a non urban area. I was without a family physician for 7 years when my wonderful prior Doctor became ill and left her practice. She made conscientious attempts to distribute her patient care load among other West a Island physicians. Not one would take any of her patients because they were already overworked.
A thorough examination of all provincial practices across Canada to ensure all Canadians have access to primary health care physicians.
A cross country standard for health care workers and a cross Canada standardized salary scale for health care workers, registered nurses, registered respiratory therapists, licensed practical nurses, personal service workers, lab technicians, physician assistants, community health care workers in remote areas.

Meds are a big deal. 1 in 9 trips to the ER are due to adverse drug events; two-thirds of these usually preventable. Also, there’s a huge proportion of unnecessary med use. Eg About 30% of antibiotics in the community are prescribed needlessly. And there is also the problem you identified around non-adherence to meds being a cause of trips to the hospital. Beyond Pharmacare, we need a mechanism to ensure medications are necessary, safe and effective. We need to capitalize on the knowledge and skills of pharmacists who remain one of the most underutilized regulated health care professionals in Canada. Pharmacist services should be part of the expanded definition of universal coverage. And their scope of practice and funding need to be harmonized across the country.

I live in British Columbia which is surely lacking an educated doctors that can fill the various treatment that is needed right now or auction and private clinics I can’t afford that and why can everybody get treatment for this disease if they live in Ontario or United States or any rust in the world by Canada which is supposed to have Universal Health Care I’m barely standing on one leg homeless no healthcare left no human rights we need to fix just because my body is broken doesn’t mean I’m not a human and I don’t matter resources resources

Although as Tom Collins points out the article hasn’t provided new ideas, the importance of this article lies in pointing out that Canada has more work to do especially as it indicates – “The Commonwealth Fund’s recent report, Mirror, Mirror, ranked Canada’s health care system as ninth among 11 countries”. Full awareness of a problem is needed before real solutions and how to go about finding solutions and mechanisms to correct the problem, can be attained. A problem in Canada is that far too many people just believe our health care system is basically flawless for whatever reason and I believe this complacency has led us down the path where we are situated now in the rankings.

Doctors need to get their own house in order. The OMA is a disaster. Poor leadership for their own profession does not bode well for health care leadership. Physicians seem to assert themselves when they really lack the ability to do so. I would also agree with around constant overt and subtle undermining of other regulated health professionals eg NPs. The arrogance of the medical profession in assuming they can solve the problems we have in health care, when doctors have been a huge contributor of problems in the healthcare system demands the need for external leadership and accountability.

Idealism from a doctor at St Mikes. Shocking. Listen, when you practice in the real world where you don’t have nurses, social workers and a whole academic team behind you, then let’s talk about real problems and helpful solutions. Let’s fund good nutrition so poor people can eat a proper diet. Let’s fund exercise programs and community centres so that people can socialize and be active together. Let’s stop incentivizing welfare and fund opportunities for education and employment. Let’s fund affordable housing. Pharmacare and dental care are much much lower on the priority list. But they keep academic doctors talking.

Dr. Raza notes the importance of equity and access, and the shortfall of both in Canada relative to other nations. So far, I agree. He then suggests that expanding our single-payer model to include drugs will solve equity and access problems. This assumption is hard to prove.

In Ontario, equity is also important in health services. It’s noted (twice) in the Minister’s mandate letter. Instead OHIP+, Ontario’s new drug plan for children and young adults under age 25, will provide equal access to the public drug plan. Young Ontarians will pay no deductible, and so will do better than the social assistance recipients and seniors already covered by the OPDP. OHIP+ will replace adequate private drug coverage instead of targeting resources to those who need coverage – the definition of equitable. So governments are no guarantee of equity, even with a mandate to do so.

The Netherlands and Germany, noted as high-performers in these rankings, have national social insurance systems with universal coverage, minimum coverage standards and regulated payer roles for employers and citizens. Neither is perfect but we can learn from them.

Dr. Raza doesn’t explain how expanding our single-payer system to include drugs will automatically cause our poor-performing system to improve equity and access. Years of Commonwealth Fund rankings indicate there is no straight line between the system model and its performance.

Rather than recommending one model over another, these rankings more directly call into question system governance. System-level plans and priorities should be accessible by the public; some should even be open to public consultation. That might inform and engage citizens and help hold governments accountable for better equity and access. Recently, the PMPRB set a good example in their guidelines and regulations review process.

We need to be careful about rushing to pharmacare with only one model, no consultation and too many assumptions.

Hear, hear. Chris Bonnett’s comment is thoughtful, evidence-based and encourages reflection. It is truly this sort of thinking that readers of Healthy Debate would benefit from. I would encourage Healthy Debate to reconsider authorship from their usual pool of writers, who all seem to have a fairly myopic view on policy.

Working in health care over 30 years and seeing the outcomes getting worse has been disheartening. Our voices have not been heard. Prevention is worth a pound of cure, but we’re still stuck on putting out fires and throwing money at crisis situations. We love sirens, bells, and whistles. Health prevention (formerly “public health”) has been virtually eliminated because acute care and chronic disease consumes all our resources. It’s time we seriously view social determinates of health (educational attainment, housing, cost of food, ability to lead an active lifestyle), as important as medication and surgeries. We need to walk and cycle more, we need to have access to affordable higher education to create jobs and work, we need affordable high quality food. We need housing – in a country the size of Canada, why are people littered over the streets? We and educational system that covers more than academics and provides children with life skills. These interventions will improve health more than a prescription drug plan.

Acedmecizing Medical issues is really dangerous. Public health care is insurance, the tax payers pay their insurance through taxes, and then others are also covered. The problem with public health care is a lack of competition and low standers than private health care. There is also ethnic divides, overuse of pharmasuticals leading to more health problems and coruption and control. People are being diagnosed with things and they are not even sick. Personally I think in health care less is more with the exception of emergercy services. Overwhelmed doctors (part time?)are good doctors not the other way around.

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.